One Therapy Rule – Part 1

MSL has done some research on a change coming our way. You may have heard of it – the “One Therapy Rule,” formally known as the EIDT Program. Watch this video and stay tuned for your opportunity to take action.

The PASSE System – How to Take Action

Updated: 4/10/18 12:10pm

The PASSE system was voted in by our legislature last year, and now the time has come for us to see the changes.

If you need a reminder, the PASSE stands for Provider-led Shared Savings Entity, and they will be managing the care for tiers 2 & 3 of behavioral health and developmental disability services.

DHS has begun to assign people to the 4 licensed PASSEs after each person’s Independent Assessment is complete.

MSL is actively working to get you more information on the PASSEs themselves. The information we have so far is listed below. If you have a question, you can call the DHS PASSE expert in your area. See the list.

These changes may be happening to you or a loved one, but you can do these 7 things to help yourself in this new process:

1. Make sure your provider knows about the PASSE and everything it involves.

Update: DHS said this week that they are in the process of setting reimbursement rates for providers – the actuary process. Because of that, some providers will not know what you mean when you mention the PASSE to them. Their business office may know and may be waiting on these rates before making any decisions. However, you can still take this information to your provider and/or to the business office.

The top 2 packets are ones that DHS has distributed to providers. Don’t assume yours has received it. Every provider you use needs to be sure they understand this. The 3rd is a collection of contact information of all PASSEs specifically for providers to help them join. Take care of yourself, and take these to every provider you see.

  • A Family letter to take to your providers that explains this for you
  • Resource that was sent to PCPs
  • Resource that explains PASSEs in depth
  • Resource that explains how to join
  • Give them the contact information below

Some have been concerned whether ACH is covered. This is the response:

“State supported hospitals UAMS and ACH will be enrolled with every PASSE. Many doctors are enrolled through their networks but may not know that yet. You can call every PASSE and interview them so you are making an informed choice.”

2. Get to know the PASSEs.

*MSL has requested websites for all – check back for updates.

Arkansas Total Care
Empower
Summit (Arkansas Provider Coalition)
ForevercARe

3. Join a PASSE Advisory Committee.

Every PASSE must have a committee of individuals and caregivers affected by the PASSE to give them feedback on what’s truly happening, especially if that doesn’t match what’s supposed to be happening. Use the contact info above to send your request to join a council.

4. Remember, you have choices.

Once you have been assigned a PASSE, you have 90 days to change to another. Call your PASSE, and make sure they include your providers. If they don’t, use the info above to find a PASSE that better suits you. We will continue to provide more info as we can!

5. If you feel lost, take some time to catch up.

What is a PASSE? Will you be affected? MSL has been following the PASSE from the very beginning. Take some time to catch up and read all about them.

6. Keep MSL informed.

If you learn anything, especially from a specific PASSE, share it with us! If you have any problems, MSL works to solve those for you. Please let us know by:

7. Think about how you’re feeling now, remember that at the next vote.

Our legislature voted this into effect. We called, we emailed, and we visited – all to let them know what we need. If you feel that this good for you, remember that, and perhaps send a note to let them know. You might want to vote for your representatives again. If you feel they didn’t listen to you or didn’t represent you well by voting for this, you should send them a letter to let them know. However, you also have the power to change who is in office. Make sure you place an informed vote. See how your local Representatives or Senators voted on Act 775.

PASSE Q&A Follow-up

DHS recently hosted a FB live about the PASSE to answer our questions, but some of your questions were not answered at that time. The images below show DHS’s follow-up answers to some of the questions.

For those of you who would like to go back and watch the Facebook live video from January 19, click here.





Live Q&A with DHS about PASSEs

MSL took your questions to DHS, and they answered live on Facebook. This video has several good demonstrations and answers that you might need to see. The PASSEs will start taking clients in February 2018.

Watch the video:

New Medicaid Dental Plan

Updated 1/3/18 09:30

 You may have received a letter telling you that your Dental plan has changed. That’s because Arkansas Medicaid has moved their dental coverage to managed care. There are 2 companies: Delta Dental and MCNA. You will be assigned to one, and you have 90 days to switch.

We requested information on the change,  and this was DHS’ response:

The Arkansas Department of Human Services is changing its dental program. Beginning January 1, 2018, two companies will provide dental coverage for families enrolled in Medicaid. Those companies are:

  1. Delta Dental of Arkansas
  2. Managed Care of North America (MCNA)

There will be no changes to the dental services that are covered. Families will be assigned to one of the two companies in December 2017 and will get new dental cards and a welcome packet in the mail for each enrolled family member.
 
If members want to switch to the other company, they will have 90 days to do so. 
Families can begin scheduling appointments for covered dental services after January 1, 2018. Information about what is covered will be in the welcome packet.
 
Clients living in Human Development Centers, individuals enrolled in the Program for All Inclusive Care for the Elderly (PACE), and individuals who are eligible for Medicaid only after incurring medical expenses that cause them to “spend down” to Medicaid eligibility levels will not be enrolled in a dental plan.

It is important to note that as new beneficiaries apply for Arkansas Medicaid benefits, if they qualify for dental benefits, it will take between 15 and 45 days for them to be assigned to a plan and for the plan to complete the enrollment process.  

Then we requested information on the difference between the companies, and this is what DHS said about the new dental plans:

The benefits are identical and the number of dentists in each network is very close to the same (within 1%). The only real difference I can recommend is for the client to check to see if their preferred dentist is in the network to which they were assigned. If confirmed, I suggest they stay with that plan. If not, they should check with the other option to see if their preferred dentist is in that network and they will have until the end of March to change plans if they want to.

Both companies are very good at what they do and have been excellent partners for us to work with.

We also asked DHS to address the rumor that ACH Dentists won’t be covered:

Delta Dental AR has 12 of 17 dental providers at ACH credentialed and in the network. The other five have submitted their applications and are undergoing the credentialing process with the expectation that they will also be admitted to the Delta network. They added that MCNA has also had a meeting with ACH, so we can hopefully expect them to cover ACH dentists as well.

After the new year, DHS sent us more clarifying information on the providers who are included:


[We want to] share the details below to demonstrate how very close the dental provider counts are between the two managed dental care organizations now serving Medicaid clients. MCNA received slightly fewer enrollees due to assignments happening by family (keeping family members in the same plan) but the total number of providers in each network varied by 1 last month. Both companies are continuing to enroll providers including ACH.

On 12/15/17 (the last phase of the auto assignment period) a total of 610,945 beneficiaries were assigned to our two dental managed care companies as follows:

  • MCNA – 304,789
  • Delta Dental of Arkansas – 306,156

As you know, there will be some movement as beneficiaries work through their 90 day choice period.

As of 12/20/17 the two MCO’s have contracted with, or have contracts pending for the following number of dental providers:

  • MCNA
  • Contracts complete – 646
  • Contracts pending – 60
  • 706 Dental Providers


  • Delta Dental of Arkansas
  • Contracts complete – 673
  • Contracts pending – 34
  • 707 Dental Providers




Independent Assessment: How to Be Prepared

Every single person who is a Tier 2 or Tier 3 and receives Medicaid services for a Developmental disability or a Behavioral health issue will undergo an Independent Assessment. This means you need to understand what it is and what will happen. MSL has gathered some resources to help you be prepared:


IMPORTANT INFORMATION

First of all, you’re probably asking, which Tier am I in? Click the link to find out!

If you are Tier 2 or 3, you will receive a notification letter about your assessment. It may come from a company you don’t recognize, but make sure to look for a letter and read carefully for the words Independent Assessment. Once you receive a letter, you will soon receive a phone call to schedule a meeting.

You are allowed to take people with you in these assessments, such as a parent or provider. The assessment itself can take from one hour to three hours. It is critical carefully consider and answer the questions because they determine your Tier placement.

Once your assessment is finished, you will have to wait to receive results. Once they are compiled, both you and your primary provider will receive a copy.


THINGS THAT CAN HELP

DHS has released the following resources to assist you or a loved one in preparation for these Independent Assessments. MSL has gathered it all in one place for you:

  • Read the full assessment itself in PDF form
  • View a presentation to explain the DDS changes
  • View a presentation on IAs for providers
  • Read the training that has been sent to PCPs

The two power point presentations may be of help what is taking place within the DD service system.  Additional information may also be found at the following website https://www.medicaid.state.ar.us/general/programs/passe.aspx.

Click on each image to access the resource.

The Full Independent Assessment people will get:Screen Shot 2017-11-14 at 11.34.00 AM


Presentation for Individuals, Families, and Staff:

Screen Shot 2017-11-14 at 11.45.56 AM


Presentation for Providers:

Screen Shot 2017-11-14 at 11.56.46 AM


Training that was sent to all PCPs:

Screen Shot 2017-11-14 at 12.00.05 PM


Previous related MSL posts:

Independent Assessment Manuals

 

 

What Tier Would I Be Placed In?

Certain people who receive Medicaid through Developmental Disability Services and/or Behavioral Health Services will be contacted about an Independent Assessment – only Tiers 2 and 3. Read the following situations to decide where you might fit:

Developmental Disability Service Tiers

Tier 1:
Individual receives DD services under the Medicaid State Plan (DDTCS, CHMS, therapy, etc.), but does not meet ICF/IID level of care eligibility

Tier 2:
Individual meets ICF/IID level of care eligibility, but does not currently require 24 hours/day of paid support and services to maintain his or her current placement

Tier 3:
Individual meets ICF/IID level of care eligibility and does require 24 hours/day of paid support and services to maintain his or her current placement


Behavioral Health Services Tiers

Tier 1: Counseling
Time-limited services provided by a qualified licensed practitioner in an outpatient setting to assess and treat mental health and/or substance abuse conditions

Tier 2: Rehabilitative
Home and community-based services with care coordination including a full array of professional and para- professional services for individuals with higher needs. Services provided by certified behavioral health agency staff members.

Tier 3: Residential
Services provided in residential setting for individuals with the highest need

Updated PASSE Information

Click the image below to receive comprehensive, updated information on the PASSE systems (as of October 2017). The deadlines have been updated, and if you were wondering what the purpose of the model is, here’s your chance to find out!

Screen Shot 2017-10-31 at 9.36.43 AM

Three PASSEs were officially certified on October 18: Arkansas Advanced Care, ARkansas Total Care and Empower Healthcare Solutions. Read more about them in the image below:

Screen Shot 2017-10-31 at 10.20.51 AM

Therapy Cap PA Requests: Q & A 


The PT, OT, and SH Association Presidents regularly meet with DHS and AFMC to discuss issues that providers have when requesting Prior Authorizations (PAs) for children who need therapy over the 90-minute cap. These are the results of their latest meeting.

Keep track of your questions and email them to be discussed at the next meeting.


The Recap of ArkSHA, ArPTA, and AROTA meeting with AFMC and DDS on 08-25-17:

The following are issues raised by members of ArkSHA, ArPTA and AROTA, and responses from AFMC and DDS.

Issue: Shifting of Units Between Therapist and Assistant

There are still questions regarding the length of time it is taking to shift units from PT/OT/ST to PTA/COTA/SLPA and vice versa. AFMC reports that following completion of the large number of DMS-640 form validations AFMC received many change requests to prior authorizations. AFMC encouraged their staff to continue to process initial DMS-640 validations and that all changes would need to be checked before processing. Currently, AFMC states that they are about 10 days out on corrections and Jarrod McClain, AFMC Director for Clinical Review, indicated that their staff are working diligently to get the updates made as quickly as possible. The updates to the PA’s flow to DXC each night and providers can start billing immediately upon receipt of the changes.

In addition, Jarrod stated that AFMC is working to decrease the timeframe for corrections but they have to ensure that they are getting the correct request ID modified. According to Jarrod, it takes a few days to check and update the claims data extract file. If providers continue to see a delay, please contact Jarrod McClain at AFMC. He will personally see that his staff checks on the status of their request and get it processed.

Issue: Use of evaluations from preschool programs to kindergarten

There was concern from many members as to how long their evaluations will be valid in a schools setting. The consensus is that if the evaluation utilized is an evaluation conducted by a non-educational agency, or by a provider who is not contracted by an educational agency, then the evaluation is good for one year. If an educational agency or a contractor of the educational agency conducted the evaluation, then the evaluation falls under the school-based evaluation criteria of every 3 years.

Issue: Some prior authorizations were only approved after sending in a cover sheet restating information included in the evaluation.

AFMC was aware of this issue and is working to improve their processes for approval. In the meantime, providers are encouraged to highlight justification for medical necessity in the evaluative reports, including statements about how the services recommended are under accepted standards of practice to treat the patient’s condition, how services are complex and will require the skilled services of a qualified therapist, and a statement about therapy prognosis (See Medicaid Manual Section II). Though a cover letter outlining these justifications is not required, providers are encouraged to consider using a cover letter attached to the evaluation to make these medical necessity statements more salient for reviewers.

Issue: Are reviewers actually reading the evaluations or just looking for technical language?

AFMC assured us that they are reading all evaluations. They perform both technical and administrative reviews in order to ensure that all requirements of the evaluative reports are included, as well as a medical necessity review to ensure that justification for medically based services is included.

Issue: I heard that AFMC was using nurse reviewers and not experienced pediatric therapists in each discipline. Is this true?

AFMC utilizes registered nurses to perform the initial reviews of all PA requests. If a request is denied than the request is assessed by an experienced licensed therapists specific to the discipline. If the therapist agrees with the denial it is then sent to a board certified pediatric physician for final review. If a provider does not agree with the denial or would like to request reconsideration they may do so by resubmitting the request.

Issue: What about beneficiaries who receive services from multiple providers for the same service?

AFMC and DDS continue to emphasize the need for care coordination for beneficiaries with multiple providers of the same modality (physical, occupational or speech therapy). Dr. Chad Rodgers, AFMC Medical Director, attended our meeting and reported that the pediatricians and PCPs he has been in contact with are interested in understanding what situations justify the appropriate signing off on multiple prescriptions. He asserts that although he can’t speak for all physicians he personally looks at every request for therapy services before signing them. He recognized that it is difficult to for most physicians to understand why a child needs multiple services. He and assistant director of DDS Elizabeth Pittman stated that it would be beneficial to state on the DMS-640 the specific need for a particular service and that the beneficiary will need the services of multiple therapists. AFMC and DDS are considering a change to the DMS-640 forms in the future to accommodate the different services provided within one discipline. Elizabeth Pittman reported that the new MMIS system (which has an anticipated implementation of summer of 2018) will be less burdensome on providers and will have the ability to disclose is the beneficiary is receiving services from other providers. Until then, providers need to ask during the intake process if the recipient is receiving therapy services from any other provider, and then coordinate as needed. According to Jarrod McClain, only 10 providers have bumped into challenges with the multiple provider issues thus far.

Issue: For short term scripts (i.e. ortho docs who write for 2-6 weeks) that then need an extension once the patient has had a follow-up recheck. What is the most efficient way to keep PA’s from having to be unnecessarily done?

Providers can simply go into Review Point, and click the extend button. The codes will be transferred over and the new prescription can be uploaded. Information about the progress of the patient and continued medical necessity should be included with the extension.

Issue: It has come to the attention of AFMC and DDS that some facilities are sending notices to parents that they should not allow services for their child in the school due to the need for a PA if the school and independent facility are both treating the beneficiary.

Although Medicaid is a “medical” assistance program, it recognizes the importance of school-based services. The federal Medicaid program actually encourages states to use funds from their Medicaid program to help pay for certain healthcare services that are delivered in the schools, providing that federal regulations are followed. The associations stand with AFMC and DDS that sending notices to parents regarding billing for services between schools and independent clinics is not recommended. IDEA laws require schools to provide services to beneficiaries if needed for educational purposes. Schools also must provide therapy that is medically necessary. Therapy services outside of the school setting should not replicate services provided by therapists contracted or working with the school.

Issue: A representative at DHS has stated that physical therapy re-eval codes are no longer a valid code as of July 1st. Has anything changed in the recent rule change?

Reevaluation codes are not currently and haven’t been a reimbursable code. The two billable codes for physical therapy services are 97001 and 97110.